Alternatives to Total Abdominal Hysterectomy

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1 October 07, 2011 By James E. Carter, MD, PhD [1] The alternatives to total abdominal hysterectomy include denial service, vaginal hysterectomy, laparoscopic-assisted vaginal hysterectomy, laparoscopic supracervical hysterectomy, endometrial ablation, and myomectomy/myolysis. INTRODUCTION The alternatives to total abdominal hysterectomy include denial service, vaginal hysterectomy, laparoscopic-assisted vaginal hysterectomy, laparoscopic supracervical hysterectomy, endometrial ablation, and myomectomy/myolysis. There are 650,000 hysterectomies performed each year in the United States with 75% these being abdominal hysterectomies and only 25% being vaginal hysterectomies. The goal healthcare reform should be to eliminate unnecessary hysterectomies and to convert abdominal hysterectomies to less invasive procedures. Sixteen percent all hysterectomies have been found to be inappropriate therapy with 25% hysterectomies in younger and 8% hysterectomies in older women deemed unnecessary.1 Once the issue the appropriateness surgery has been dealt with, the issue becomes "Is the choice abdominal hysterectomy appropriate? or is another therapy possible?" DEFINITIONS By way definitions, an abdominal hysterectomy is removal the uterus with or without the ovaries through an incision approximately 5 inches wide in the abdomen. A vaginal hysterectomy is the removal the uterus with or without the ovaries through an incision in the vaginal area. Endometrial ablation refers to hysteroscopic removal or destruction the lining the uterus down to the level the uterine muscle. Laparoscopic-assisted vaginal hysterectomy refers to the use a laparoscope to allow the performance hysterectomy through a vaginal means that would have otherwise required an abdominal approach. Laparoscopic supracervical hysterectomy refers to removal the uterus utilizing a laparoscope but leaving the cervix in place. Laparoscopic myomectomy refers to removal fibroid tumors from the uterus and subsequent removal the fibroids from the pelvic cavity by morcellation or extraction using minimally invasive techniques. Myolysis refers to laparoscopic destruction fibroid tumors using either laser or electrical energy so that they do not recur. INDICATIONS The indications for the various therapies are shown in Table 1. An abdominal hysterectomy is appropriate for fibroids, bleeding, pain and cancer. Laparoscopic supracervical hysterectomy is appropriate for fibroids, bleeding, and pain but is not appropriate for a cancer patient. Using this table, one can seek out an alternative to abdominal hysterectomy for the specific problem with which the patient presents. CRITICAL PARAMETERS The critical parameters for the surgical procedures that are alternatives to the abdominal hysterectomy are shown in Table 2. Page 1 5

2 An abdominal hysterectomy requires 4 to 5 days hospital stay with a recovery time for patients 6 to 8 weeks. Vaginal hysterectomy requires a hospital stay only 1 to 2 days and 7 to 14 days recovery time. Both the laparoscopic-assisted vaginal hysterectomy and laparoscopic supracervical hysterectomy have comparable lengths stay and recovery times to vaginal hysterectomy. Endometrial ablation requires only 30 minutes to 1 hour to complete and a brief stay in an outpatient setting. It requires a recovery time only 2 to 4 days. Myolysis has similar parameters to the endometrial ablation. abdominal hysterectomy to alternative procedures potentially could save 4 to 6 weeks recovery time and 2 to 4 hospital days per patient. If these alternative procedures could be performed for all 487,500 patients currently being treated with abdominal hysterectomy, this would amount to almost 2 million hospital days saved per year. A goal healthcare reform should be to convert as many abdominal procedures as possible to the alternatives to obtain as much the savings as possible both in patient recovery and in hospital days. Dysfunctional Uterine Bleeding: Dysfunctional uterine bleeding is a major cause for hysterectomy. Endometrial ablation can frequently replace hysterectomy for the treatment bleeding disorders. This procedure takes 30 minutes to 1 hour to perform, requires only a few hours observation in an outpatient setting postoperatively, and has a very short recovery time for the patient. In order to ensure that patients are satisfied with the results the procedure, however, it is important that the ablation be performed thoroughly. It has been demonstrated that the success endometrial ablation is dependent upon uniform destruction the endometrium and superficial portion the myometrium.2 In order to ensure this uniform destruction the endometrium, GnRH agonists are used for pretreatment for a period one to three months. GnRH agonists prepare the endometrium by uniformly reducing thickness, decreasing edema, and avoiding pseudodecidual reaction usually present with other hormonal treatment. Uterine Fibroids: Uterine fibroids can be treated by myomectomy, myolysis, laparoscopic-assisted vaginal hysterectomy, laparoscopic supracervical hysterectomy, or vaginal hysterectomy. It has been shown that uterine fibroids contain estrogen receptors and are responsive to hormonal manipulation. Since GnRH agonists induce a state hypoestrogenism, they are effective in treating uterine fibroids. In fact, uterine fibroid will decrease by an average 57% over a six-month course treatment by GnRH agonists.3 If uterine fibroids are causing menorrhagia with anemia, uterine pressure or pain, or are otherwise causing symptoms, then treatment is appropriate. Twenty-seven percent or 175,000 the hysterectomies performed in the United States annually are performed for fibroids. In addition, myomectomy is performed in 28,000 patients per year. Because GnRH agonists shrink the uterus and fibroids, it is possible to administer a GnRH agonist for two months and increase the frequency vaginal hysterectomy over abdominal hysterectomy. In fact, in one study, 76% GnRH agonist-treated patients had a vaginal hysterectomy versus 16% nontreated patients.4 The use GnRH agonists can make possible a conversion from abdominal hysterectomy to either vaginal hysterectomy or laparoscopic-assisted vaginal hysterectomy or laparoscopic supracervical hysterectomy. Laparoscopic myolysis can also be proposed as an alternative to abdominal hysterectomy in cases large or multiple intramural fibroids in women over 40 who do not desire to bear children but who wish to avoid hysterectomy.5,6 Page 2 5

3 Laparoscopic myolysis is performed by inserting a laser fiber or bipolar electrosurgery electrode into the fibroid. This is performed after pretreatment by GnRH agonist for a period two to three months. After myolysis has been performed, a full six-month course GnRH agonist treatment is completed. As a result this therapy, uterine volume can be reduced by 41% within one year.5 In 200 cases using a combination laser and GnRH agonists, a reduction in volume 70% the fibroid size was accomplished at one year.6 Myolysis, therefore, can be considered an effective therapy for the reduction fibroid size and can be proposed as an alternative to myomectomy or hysterectomy in selected patients. Laparoscopic myomectomy can also be accomplished. In one study, 92 myomas were removed in 43 patients. To avoid the need for transfusion, the patients were systematically treated preoperatively with GnRH agonist.7 Endometriosis: For treatment pain, both laparoscopic surgery with procedures such as laparoscopic excision endometriosis, laparoscopic uterosacral nerve vaporization, and laparoscopic presacral neurectomy can be performed to prevent the need for hysterectomy. In one study, GnRH agonists were given for six months for the treatment endometriosis without surgical intervention. These patients were followed for a period five years, and it was found that 46.6% were cured by the six-month course GnRH agonist therapy.8 In patients with pelvic pain and endometriosis, a trial medical therapy with GnRH agonists is warranted because long-lasting benefits occur in about half the women treated. Half these patients, however, will have recurrence the disease, requiring retreatment or surgical intervention.8 CONCLUSION In conclusion, pretreatment with GnRH agonist has been demonstrated to be an effective means to allow many who previously would have required abdominal surgery to convert to less traumatic alternatives. These alternatives would permit a great savings for the patient in hospital time, pain, suffering, and time f work as well as decreasing the risks surgery in terms infection, blood loss, and complications. Pretreatment with GnRH agonists can have the following effects: 1) 2) 3) 4) 5) 6) Elimination abdominal to vaginal surgery. abdominal to laparoscopic-assisted vaginal surgery. abdominal hysterectomy to endometrial ablation. the need for surgery altogether. need for hysterectomy to myomectomy or myolysis. abdominal surgery to laparoscopic procedures. The integration GnRH agonists into our treatment armamentarium holds forth an opportunity for great benefits to our patients in our quest to perform more minimally invasive and less traumatic surgical procedures. ADDENDUM (Reprinted with permission from the Society Laparoendoscopic Surgeons.) Carter JE. Laparoscopic myomectomy. In Kavic MS, Levinson CJ, Wetter PA, eds. Prevention and Management Laparoendoscopic Surgical Complications. Miami: Society Laparoendoscopic Surgeons; 1999: ) Arterial Embolization for Treatment Uterine Myomata: The goal minimally invasive surgery is to provide treatment the affected portion an organ while preserving the organ itself through incisions and ports as small as possible while maintaining a safe environment for the patient. The Page 3 5

4 procedure arterial embolization for the treatment uterine myomata is perhaps the least invasive all methods available for treatment this benign.27 Unilateral femoral artery catheterization was performed and the pelvic arteries mapped to identify uterine arteries and visualize tumor hypervascularization. The right and left uterine arteries were then catheterized and inert particles Ivalon were introduced in free-flow, gradually increasing the size the particles until tumor blood flow was eliminated. After completion embolization, a fragment Spongel was left in the trunk the uterine artery to ensure stability the devascularization.28 Menorrhagia was controlled, menstrual cycles returned to normal, and anemia resolved in 9 14 patients. Menorrhagia decreased considerably in three patients as anemia resolved, but remained bothersome and required curettage in two cases wherein simple hyperplasia was discovered.28 Two failures occurred: one with a pedunculated submucosal myoma in the process being expelled through the cervix and a second with multiple interstitial and submucosal myomata who required myomectomy after six months because persistent uterine bleeding. Embolization myoma did cause pelvic pain which was sometimes intense. It is probably the ischemic origin and starts at the time embolization and usually lasts 6-12 hours.28 This pain requires analgesia, including intravenous anti-inflammatory drugs and patient-controlled intravenous injection narcotic analgesics.28 The use preoperative Lupron depot (3.75 mg IM) (TAP Pharmaceutical, Deerfield, IL) for one to three months reduces the caliber uterine arteries by up to 50%. In an early series this has resulted in a 50% reduction in the quantity Ivalon particles used and a reduction in pain such that only mild oral analgesics are required.29 The treatment benign leiomyomata the uterus by arterial embolization techniques is a promising and exciting approach to reducing the invasiveness required for treatment symptomatic disease and reducing the risks associated with many surgical procedures Table 1. Alternatives to abdominal hysterectomy. Indications for uterine treatment. Procedure Fibroids Bleeding Pain Cancer Abdominal Hysterectomy Vaginal Hysterectomy LAVH LSH Endometrial Ablation/Resection (submucous) Myomectomy/ Myolysis * * *with laparoscopic node dissection. Table 2. Alternatives to total abdominal hysterectomy. Critical parameters for surgical procedures. Procedure Length Stay Surgery Time Recovery Time Abdominal Hysterectomy 4-5 days 6-8 weeks Complication Rate 10-15% Page 4 5

5 Vaginal Hysterectomy LAVH LSH Endometrial Ablation Myomectomy/ Myolysis 1-2 days 7-14 days 3-7% 1-2 days 1 day Less than 1 day hours 14 days 7-14 days 30 minutes - 1 hour 2-4 days 3-7% 1-4% 1-2% Less than 1 day Less than 3% 2-4 hours Disclosures: Source URL: Links: [1] Page 5 5